Abstract Number ‐ 211: Flow Diversion in Direct Carotid‐Cavernous Fistulas: Case Report and Literature Review

Abstract

Introduction Direct carotid‐cavernous fistulas (dCCF) are acquired, abnormal high‐flow connections between the internal carotid artery and cavernous sinus. Interventions are often required due to the high risk of incipient morbidity and mortality if left untreated. Treatment approaches have rapidly evolved over time, and have included the use of detachable balloons, liquid embolic agents, and coil embolization through transarterial, transvenous, or combined approaches. Case series level data support an emerging role for the use of flow diversion (FD) as a stand‐alone or adjunctive treatment in dCCFs. We describe a case of FD use as an adjunctive treatment in a patient with a treatment‐resistant dCCF, and review the literature on FD use in dCCF. Methods We describe the clinical course, imaging findings, and outcomes of a 25‐year old patient who presented with a traumatic carotid‐cavernous fistula requiring multiple interventions. We also performed a literature review of Pubmed and Embase databases using combinations of MeSH and key terms to include all relevant full‐text publications of FD use in the treatment of dCCFs, up to and including February 2022. Results Our patient achieved angiographic cure and significant improvement in symptoms at 6‐month follow‐up. A total of 24 papers were identified and included, for a total number of 53 cases (23 male, 23 female, 7 unspecified). The median age of patients was 44 years (Interquartile range (IQR) 23–62). The etiology of the dCCF was traumatic (acute or as a delayed presentation) in 31 cases (58%), spontaneous in 10 cases (19%), and iatrogenic in 12 cases (23%). FD was the primary mode of treatment of the CCF in approximately half of cases (27, 51%), and was a stand‐alone treatment modality in one third of cases (18, 34%). The median number of FD devices used on initial treatment was 1 device, though retreatment was needed in 42% of cases.Angiographic resolution was achieved in 90% of cases at a median follow‐up duration of 6 months.One half of all patients had complete resolution of symptoms and a further third noted clinical improvement in at least some of their symptoms. In 10% of cases, symptoms persisted, or other complications developed that were attributed to concurrent injuries. Conclusions Treatment approaches for dCCFs have evolved over time as safer and more effective treatments become available. There is an emerging role for FD as a safe stand‐alone or adjunctive treatment option for dCCFs. Our case further supports its role in treatment‐resistant fistulas with high‐risk features. As treatment approaches continue to evolve, prospective randomized data is needed to better establish the role of flow divertors among the hierarchy of available treatment options for dCCFs.